Radiation exposure during the lateral lumbar interbody fusion procedure and techniques to reduce radiation dosage

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. 4. The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

37. Outpatient minimally invasive lumbar fusion using multimodal analgesic management in the ambulatory surgery setting

Lateral lumbar interbody fusion (LLIF) has proved to be a safe tool in the armamentarium of spine surgeons for a variety of lumbar disorders. However, it has some complications related to specific approaches. Incisional hernia following abdominal surgery and anterior spinal surgery is commonly described; however, it is extremely rare following LLIF, with only 1 case reported in short postoperative period. In this report we present the first case of delayed presentation of true incisional hernia following a LLIF procedure and highlight its presentation, mechanism, possible preventive measures, and management. We report a 57-year-old lady who underwent L3-4 LLIF. She presented with vague pain in a healed scar area that had no swelling until two years postsurgery, when she developed a painful swelling. On examination, it appeared to be a herniation of abdominal contents. She underwent a laparoscopic hernia repair surgery. The muscular layers were found to be intact with an attenuated transversalis fascia layer. The repair was reinforced by polypropylene mesh. There was no recurrence at the 6-month follow-up. Incisional hernia can occur following LLIF months to years following surgery and can have varied presentation. Tight external oblique closure should be performed because the transversalis fascia often cannot be repaired and the quality of a layered closure of the deep obliques is often disappointing. The treating surgeon should be aware of this complication and aggressively surveil for the warning signs, and patients should be counseled about this potential complication.

Prospective in vivo radiation exposure study. To assess surgeon exposure to ionizing radiation in the setting of lateral lumbar interbody fusion (LLIF). Minimally invasive spine surgery relies heavily on image guidance. Rapid popularization of minimally invasive spine surgery procedures, such as LLIF, is appropriately accompanied by concern regarding occupational radiation exposure related to intraoperative fluoroscopy. Optically stimulated luminescence technology dosimeters were used to record radiation exposure prospectively at 5 anatomic locations during 18 LLIF procedures: (1) eye, (2) thyroid, (3) chest, (4) axilla, and (5) gluteal region. Additionally, a ring dosimeter was worn during 13 of the LLIF cases. Average fluoroscopy time was 88.7 ± 36.8 seconds and skin dose to the patient was 25.2 ± 21.1 mGy. The chest dosimeter protected by lead recorded the lowest readings per procedure (0.44 ± 0.49 mrem). The gluteal dosimeter recorded an average exposure of 2.31 ± 4.50 mrem and the dosimeter at the axilla recorded an average of 4.20 ± 7.76 mrem per procedure. Exposure to the thyroid and eye were 2.19 ± 2.07 mrem and 2.64 ± 2.76 mrem, respectively. With the exception of the gluteal region, dosimeter readings from all unprotected areas were significantly higher than those from the chest dosimeter (P < 0.0125). In the course of 13 procedures, 190 mrem of exposure to the hand was recorded by the ring dosimeters. More than 2700 LLIF procedures may be performed annually before occupational limits are exceeded. Prolonged exposure to "low-level" radiation as an occupational risk remains a concern for medical personnel. Radiation exposures to unprotected, radiosensitive locations, such as the axilla or eye, are worrisome. However, following radiation safety guidelines, 2700 LLIF procedures can be performed per year before exceeding occupational dose limits. Adherence to radiation safety guidelines is necessary to avoid sequelae related to an invisible but potentially deadly risk of minimally invasive spine surgery procedures.

The lateral lumbar interbody fusion (LLIF) procedure is a minimally invasive procedure that has become widely utilized. The LLIF procedure typically involves bending the table to access the disc spaces of interest due to anatomical constraints. It is unknown if this bending process is painful or what pressures are exhibited on the downside part of the body. The goal of the study was to determine whether sex, height, weight, body mass index, bed angle, or positioning relative to the break of the bed affects the downside skin pressures and VAS pain scores in awake volunteers. Fifty-six volunteers were placed in the lateral decubitus position and pressure sensors were placed at the downside part of their anatomy (shoulder, T10 rib , iliac crest, and greater trochanter). The pressures were checked with the iliac crest or greater trochanter at 0, 10, 20, 30, 40 degree bed angles. VAS scores were checked when the iliac crest or greater trochanter were at the maximum bed break angles. A significant positive association was found between increased bed angle and pressure at all five areas on the downside body locations (p<0.0001). The greatest pressures were located at the iliac crest and greater trochanter when these specific locations were centered over the break of the bed (p<0.0001). When the iliac crest was placed at maximal bed break, each unit increase in BMI increased the VAS pain by 0.13 (p<0.0001)and men had 1.96 (p=0.0009)higher VAS scores then women. When the greater trochanter was placed at the maximal bed break, each unit increase in BMI decreased VAS pain by 0.19 (p<0.0001) and women had 1.55 (p=0.0002)higher VAS pain scores then men. In awake volunteers, the pressure at the iliac crest or greater trochanter at the break of the bed increases by increasing the bed angle. Women with a lower BMI had high VAS pain scores when their greater trochanter was at maximal bed break. Men with higher BMI had high VAS pain scores when their iliac crest was at maximal bed break. An awareness of the iliac crest or greater trochanter at the break of the bed should be considered to prevent pain and increased pressure based on the patient's sex and BMI.

Femoral nerve neuromonitoring for lateral lumbar interbody fusion surgery

Lateral lumbar interbody fusion procedures are performed with multimodality neuromonitoring of the femoral nerve to prevent lumbosacral plexus and peripheral nerve injury from positioning, dilation, retraction, and hardware implantation. The integrity of the femoral nerve can be continuously assessed during these procedures by Somatosensory Evoked Potentials of the Saphenous nerve (Sn-SSEPs). Sn-SSEPs are technically challenging to acquire and necessitate advanced troubleshooting skills with a more rigid anesthetic regimen and physiological parameters. We performed a retrospective analysis of Sn-SSEP data for 100 consecutive lateral lumbar surgeries where the stimulation electrodes were placed distally below the knee and medial to the tibia bone (i.e., DSn-SSEPs). Monitorable baseline responses were present in 87% of patients after the exclusion of fourteen cases where the tibial nerve SSEP was absent, quadriceps transcranial electrical motor evoked potentials (TCeMEPs) were absent or not utilized. Sex, age, body mass index (BMI), diagnosis, mean arterial pressure (MAP), inhalational anesthetic levels, reliability of ulnar and posterior tibial nerve SSEPs, and the reliability of femoral nerve innervated quadriceps TCeMEPs were evaluated but were not of statistically significant consequence between cases where the DSn-SSEP was present or absent in this study. We found the utilization of DSn-SSEPs to be a valuable adjunct to femoral nerve monitoring. Stimulation electrode placement is easy to palpate with clear anatomical borders. Significant muscle artifact and patient movement from stimulation do not affect waveform morphology, allowing for continuous and reliable monitoring. We recommend including DSn-SSEPs to optimize recordings during lateral lumbar procedures.

Study DesignRetrospective case-control study.PurposeWe aimed to compare radiologic outcomes between posterior (PLIF) and lateral lumbar interbody fusion (LLIF) in short-level spinal fusion surgeries.Overview of LiteratureAlthough LLIF enables surgeons to insert large lordotic cages, it is unknown whether LLIF more effectively corrects local and global sagittal alignments compared with PLIF in short-level spinal fusion surgeries.MethodsRadiographic data acquired from patients with lumbar interbody fusion (≤3 levels) using PLIF or LLIF for degenerative lumbar diseases were analyzed. The following radiographic parameters were evaluated preoperatively and at 2 years postoperatively: segmental lordotic angle, disk height, lumbar lordosis (LL), pelvic tilt (PT), C7 sagittal vertical axis, and thoracic kyphosis (TK).ResultsIn total, 144 patients with PLIF (193 fused levels) and 101 with LLIF (159 fused levels) were included. Patients’ backgrounds and preoperative radiographic parameters for any level of fusion did not differ significantly between PLIF and LLIF procedures. The LLIF group exhibited significantly greater changes at 1-level fusion compared to the PLIF group in the parameters of segmental lordotic angle (5.1°±5.8° vs. 2.1°±5.0°, p<0.001), disk height (4.2±2.3 mm vs. 2.2±2.0 mm, p<0.001), LL (7.8°±7.6° vs. 3.9°±8.6°, p=0.004), and PI–LL (−6.9°±6.8° vs. −3.6°±10.1°, p=0.03). While, a similar trend was observed regarding 2-level fusion, significantly greater changes were only observed in LL (12.1°±11.1° vs. 4.2°±9.1°, p=0.047) and PI–LL (−11.2°±11.3° vs. −3.0°±9.3°, p=0.043), PT (−6.4°±4.9° vs. −2.5°±5.3°, p=0.049) and TK (7.8°±11.8° vs. −0.3°±9.7°, p=0.047) in the LLIF group at 3-level fusion.ConclusionsLLIF provides significantly better local sagittal alignment than PLIF in 1- or 2-level fusion cases and improves spinopelvic alignment and local alignment for 3-level fusion cases. Thus, LLIF was demonstrated to be a useful lumbar interbody fusion technique, constituting a powerful tool for achieving sagittal realignment with minimal surgical invasiveness.

&lt;p dir="ltr"&gt;Background: Intraoperative imaging in spine surgery, such as lateral radiographs and 2D fluoroscopy, was first used in the 1970s. Cone beam computed tomography (CBCT), which utilizes 3D technology, was introduced in the 1990s. Initially developed for dental imaging, CBCT has expanded into various fields, including spine surgery, interventional procedures and musculoskeletal radiology. In spine surgery CBCT helps spine surgeons to identify and correct malplaced pedicle screws before finalizing the procedure, potentially eliminating revision surgeries. However, this imaging technology raises radiation exposure concerns for patients and staff. Furthermore, while postoperative multidetector computed tomography (MDCT) scans remain standard for confirming results, the convergence in image quality between CBCT and MDCT creates opportunities to streamline workflows and reduce redundant imaging, decreasing radiation exposure and healthcare costs. Among individuals with cervical spine injuries requiring surgical fixation, traumatic vertebral artery injury (VAI) presents a significant and potentially dangerous complication. While detection of VAI has improved through routine CT angiography (CTA), modern hybrid operating rooms (OR) equipped with CBCT technology used both in spine surgery and interventional procedures, offer a promising advancement: the ability to diagnose and treat both spinal and vascular injuries in a single session. This integrated approach could streamline patient care and potentially lead to better clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Purpose: To investigate multiple aspects of spine surgery conducted within a hybrid OR. We evaluated occupational radiation exposure from various imaging equipment and different radiation protection shields (Paper I), compared the accuracy of CBCT with postoperative MDCT for detecting pedicle screw breaches (Paper II), assessed whether intraoperative CBCT provides equivalent image quality to postoperative MDCT to potentially reduce cumulative radiation exposure (Paper III), and examined the risk factors, incidence, outcomes, and imaging indicators of VAI in patients treated surgically for subaxial cervical spine injuries in trauma (Paper IV).&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: In Paper I, scatter radiation was measured in a hybrid OR while imaging an anthropomorphic phantom with three systems: ceiling-mounted hybrid C-arm cone beam CT (hCBCT), mobile O-arm CBCT (oCBCT), and mobile 2D C-arm fluoroscopy. Measurements were taken at various room positions utilizing active personal dosimetry devices and an ionization chamber. Two different radiation protection shields were assessed. Paper II evaluated 260 pedicle screws in twenty spinal fixation patients using intraoperative CBCT and follow-up MDCT. Three neurosurgeons independently graded pedicle screw breach using the Gertzbein scale, with MDCT as reference standard. The diagnostic evaluation methods assessed sensitivity, specificity, and negative predictive value. In Paper III, twenty-seven spinal fixation cases were examined, comparing intraoperative CBCT with postoperative MDCT. Four neuroradiologists independently evaluated images using Likert scales, and visual grading analysis measured modality preferences. Observer agreement was quantified through ICC analysis while image quality was objectively measured via contrast- and signal-to-noise ratios (CNR, SNR). In Paper IV, traumatic subaxial injuries that were surgically treated during a twelve-year period were analyzed, with mortality and morbidity as primary outcomes. Propensity score matching was used to create comparable groups, survival analysis tracked outcomes over time, single- and multiple- variable analyses examined the clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Main Results: Paper I found that OR personnel were exposed to approximately 22% lower radiation when procedures utilized the hCBCT equipment compared to operations conducted with the oCBCT system. The scattered radiation doses emitted from the hCBCT were observed to be 27% less than those from the oCBCT when measured at 200 cm from the phantom. A single rotation for image acquisition utilizing hCBCT corresponded to 12 minutes of C-arm fluoroscopy, whereas the oCBCT corresponded to 16 minutes. The scatter dose decreased by over 90% behind radiation protection shielding, although this protective effect diminished slightly when measured at greater distances (60 cm), likely attributable to secondary radiation reflection from ceilings and walls. In Paper II intraoperative CBCT demonstrated a high negative predictive value of 99.6% in ruling out pedicle screw breaches. It also showed a sensitivity of 90.0% and a specificity of 97.6% in detecting screw accuracy compared to postoperative MDCT. In Paper III intraoperative CBCT was the superior modality in the thoracolumbar spine. Conversely, postoperative MDCT was preferred in cervical spine. The agreement was good for inter-observers and moderate in intra- observers. SNR and CNR were comparable in thoracolumbar imaging, while MDCT provided superior and more consistent image quality in the cervical spine. In Paper IV, our analysis revealed that VAI was predominantly associated with significant high-energy trauma, particularly collisions from motor vehicles, same-and high-level falls, with a demographic profile of male predominance with an age distribution centered at 64.4 years. Two-thirds of the cases with VAI also exhibited spinal cord trauma, with this injury combination linked to higher levels of neurological dysfunction. When adjusting for demographic variables our analysis revealed that VAI showed no significant impact on complications arising after surgery, immediate or extended recovery outcomes, or survival rates. Facet joint dislocation was a distinctive imaging indicator that predicted VAI.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: In Paper I, hCBCT reduced occupational radiation exposure compared to oCBCT in image-guided spine surgery. Staff can lower radiation exposure through optimal positioning relative to the radiation source, patient, walls and ceilings. This allows for the use of RPSs instead of lead aprons during imaging, improving comfort while reducing whole-body dose. Intraoperative CBCT imaging in Paper II proved to be reliable and equivalent to postoperative MDCT scanning in detecting malpositioned pedicle screws in the thoracolumbar spine, potentially eliminating the need for an additional postoperative MDCT examination. In Paper III, CBCT offered superior image quality for thoracolumbar imaging, while MDCT was better suited for cervical imaging. Intraoperative CBCT could potentially replace postoperative MDCT for thoracolumbar spine procedures, though postoperative MDCT remains essential for cervical spine evaluation. Paper IV found that VAI did not negatively affect the clinical results in surgically treated cervical spine injuries. Although multiple imaging features showed associations with VAI, facet joint dislocation was the only standalone predictor of VAI.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Radiation distribution in a hybrid operating room, utilizing different X-ray imaging systems: investigations to minimize occupational exposure. &lt;b&gt;Cewe P,&lt;/b&gt; Vorbau R, Omar A, Elmi-Terander A, Edström E. J Neurointerv Surg. 2022 Nov;14(11):1139-1144. &lt;a href="https://doi.org/10.1136/neurintsurg-2021-018220" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1136/neurintsurg-2021-018220&lt;br&gt;&lt;/a&gt;&lt;br&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Intraoperative cone beam computed tomography is as reliable as conventional computed tomography for identification of pedicle screw breach in thoracolumbar spine surgery. Burström G*, &lt;b&gt;Cewe P*&lt;/b&gt;, Charalampidis A, Nachabe R, Söderman M, Gerdhem P, Elmi-Terander A, Edström E. Eur Radiol. 2021 Apr;31(4):2349-2356. &lt;a href="https://doi.org/10.1007/s00330-020-07315-5" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1007/s00330-020-07315-5&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. Image Quality Assessment in Spine Surgery: A Comparison of Intraoperative CBCT and Postoperative MDCT. &lt;b&gt;Cewe P,&lt;/b&gt; Skorpil M, Fletcher-Sandersjöö A, VG El-Hajj, Grane P, Fagerlund M, Kaijser M, Elmi-Terander A, Edström E. Acta Neurochir. 167, 94 (2025). &lt;a href="https://doi.org/10.1007/s00701-025-06503-w" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1007/s00701-025-06503-w&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Traumatic Vertebral Artery Injury After Subaxial Cervical Spine Injuries: Incidence, Risk Factors, and Long-Term Outcomes: A Population-Based Cohort Study. El-Hajj VG*, Habashy KJ*, &lt;b&gt;Cewe P*&lt;/b&gt;, Atallah E, Singh A, Fletcher-Sandersjöö A, Bydon M, Fagerlund M, Jabbour P, Gerdhem P, Elmi-Terander A, Edström E. Neurosurgery. 2024 Sep 20. &lt;a href="https://doi.org/10.1227/neu.0000000000003173" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1227/neu.0000000000003173&lt;/a&gt;&lt;/p&gt;

&lt;p dir="ltr"&gt;Background: Intraoperative imaging in spine surgery, such as lateral radiographs and 2D fluoroscopy, was first used in the 1970s. Cone beam computed tomography (CBCT), which utilizes 3D technology, was introduced in the 1990s. Initially developed for dental imaging, CBCT has expanded into various fields, including spine surgery, interventional procedures and musculoskeletal radiology. In spine surgery CBCT helps spine surgeons to identify and correct malplaced pedicle screws before finalizing the procedure, potentially eliminating revision surgeries. However, this imaging technology raises radiation exposure concerns for patients and staff. Furthermore, while postoperative multidetector computed tomography (MDCT) scans remain standard for confirming results, the convergence in image quality between CBCT and MDCT creates opportunities to streamline workflows and reduce redundant imaging, decreasing radiation exposure and healthcare costs. Among individuals with cervical spine injuries requiring surgical fixation, traumatic vertebral artery injury (VAI) presents a significant and potentially dangerous complication. While detection of VAI has improved through routine CT angiography (CTA), modern hybrid operating rooms (OR) equipped with CBCT technology used both in spine surgery and interventional procedures, offer a promising advancement: the ability to diagnose and treat both spinal and vascular injuries in a single session. This integrated approach could streamline patient care and potentially lead to better clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Purpose: To investigate multiple aspects of spine surgery conducted within a hybrid OR. We evaluated occupational radiation exposure from various imaging equipment and different radiation protection shields (Paper I), compared the accuracy of CBCT with postoperative MDCT for detecting pedicle screw breaches (Paper II), assessed whether intraoperative CBCT provides equivalent image quality to postoperative MDCT to potentially reduce cumulative radiation exposure (Paper III), and examined the risk factors, incidence, outcomes, and imaging indicators of VAI in patients treated surgically for subaxial cervical spine injuries in trauma (Paper IV).&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: In Paper I, scatter radiation was measured in a hybrid OR while imaging an anthropomorphic phantom with three systems: ceiling-mounted hybrid C-arm cone beam CT (hCBCT), mobile O-arm CBCT (oCBCT), and mobile 2D C-arm fluoroscopy. Measurements were taken at various room positions utilizing active personal dosimetry devices and an ionization chamber. Two different radiation protection shields were assessed. Paper II evaluated 260 pedicle screws in twenty spinal fixation patients using intraoperative CBCT and follow-up MDCT. Three neurosurgeons independently graded pedicle screw breach using the Gertzbein scale, with MDCT as reference standard. The diagnostic evaluation methods assessed sensitivity, specificity, and negative predictive value. In Paper III, twenty-seven spinal fixation cases were examined, comparing intraoperative CBCT with postoperative MDCT. Four neuroradiologists independently evaluated images using Likert scales, and visual grading analysis measured modality preferences. Observer agreement was quantified through ICC analysis while image quality was objectively measured via contrast- and signal-to-noise ratios (CNR, SNR). In Paper IV, traumatic subaxial injuries that were surgically treated during a twelve-year period were analyzed, with mortality and morbidity as primary outcomes. Propensity score matching was used to create comparable groups, survival analysis tracked outcomes over time, single- and multiple- variable analyses examined the clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Main Results: Paper I found that OR personnel were exposed to approximately 22% lower radiation when procedures utilized the hCBCT equipment compared to operations conducted with the oCBCT system. The scattered radiation doses emitted from the hCBCT were observed to be 27% less than those from the oCBCT when measured at 200 cm from the phantom. A single rotation for image acquisition utilizing hCBCT corresponded to 12 minutes of C-arm fluoroscopy, whereas the oCBCT corresponded to 16 minutes. The scatter dose decreased by over 90% behind radiation protection shielding, although this protective effect diminished slightly when measured at greater distances (60 cm), likely attributable to secondary radiation reflection from ceilings and walls. In Paper II intraoperative CBCT demonstrated a high negative predictive value of 99.6% in ruling out pedicle screw breaches. It also showed a sensitivity of 90.0% and a specificity of 97.6% in detecting screw accuracy compared to postoperative MDCT. In Paper III intraoperative CBCT was the superior modality in the thoracolumbar spine. Conversely, postoperative MDCT was preferred in cervical spine. The agreement was good for inter-observers and moderate in intra- observers. SNR and CNR were comparable in thoracolumbar imaging, while MDCT provided superior and more consistent image quality in the cervical spine. In Paper IV, our analysis revealed that VAI was predominantly associated with significant high-energy trauma, particularly collisions from motor vehicles, same-and high-level falls, with a demographic profile of male predominance with an age distribution centered at 64.4 years. Two-thirds of the cases with VAI also exhibited spinal cord trauma, with this injury combination linked to higher levels of neurological dysfunction. When adjusting for demographic variables our analysis revealed that VAI showed no significant impact on complications arising after surgery, immediate or extended recovery outcomes, or survival rates. Facet joint dislocation was a distinctive imaging indicator that predicted VAI.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: In Paper I, hCBCT reduced occupational radiation exposure compared to oCBCT in image-guided spine surgery. Staff can lower radiation exposure through optimal positioning relative to the radiation source, patient, walls and ceilings. This allows for the use of RPSs instead of lead aprons during imaging, improving comfort while reducing whole-body dose. Intraoperative CBCT imaging in Paper II proved to be reliable and equivalent to postoperative MDCT scanning in detecting malpositioned pedicle screws in the thoracolumbar spine, potentially eliminating the need for an additional postoperative MDCT examination. In Paper III, CBCT offered superior image quality for thoracolumbar imaging, while MDCT was better suited for cervical imaging. Intraoperative CBCT could potentially replace postoperative MDCT for thoracolumbar spine procedures, though postoperative MDCT remains essential for cervical spine evaluation. Paper IV found that VAI did not negatively affect the clinical results in surgically treated cervical spine injuries. Although multiple imaging features showed associations with VAI, facet joint dislocation was the only standalone predictor of VAI.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Radiation distribution in a hybrid operating room, utilizing different X-ray imaging systems: investigations to minimize occupational exposure. &lt;b&gt;Cewe P,&lt;/b&gt; Vorbau R, Omar A, Elmi-Terander A, Edström E. J Neurointerv Surg. 2022 Nov;14(11):1139-1144. &lt;a href="https://doi.org/10.1136/neurintsurg-2021-018220" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1136/neurintsurg-2021-018220&lt;br&gt;&lt;/a&gt;&lt;br&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Intraoperative cone beam computed tomography is as reliable as conventional computed tomography for identification of pedicle screw breach in thoracolumbar spine surgery. Burström G*, &lt;b&gt;Cewe P*&lt;/b&gt;, Charalampidis A, Nachabe R, Söderman M, Gerdhem P, Elmi-Terander A, Edström E. Eur Radiol. 2021 Apr;31(4):2349-2356. &lt;a href="https://doi.org/10.1007/s00330-020-07315-5" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1007/s00330-020-07315-5&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. Image Quality Assessment in Spine Surgery: A Comparison of Intraoperative CBCT and Postoperative MDCT. &lt;b&gt;Cewe P,&lt;/b&gt; Skorpil M, Fletcher-Sandersjöö A, VG El-Hajj, Grane P, Fagerlund M, Kaijser M, Elmi-Terander A, Edström E. Acta Neurochir. 167, 94 (2025). &lt;a href="https://doi.org/10.1007/s00701-025-06503-w" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1007/s00701-025-06503-w&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Traumatic Vertebral Artery Injury After Subaxial Cervical Spine Injuries: Incidence, Risk Factors, and Long-Term Outcomes: A Population-Based Cohort Study. El-Hajj VG*, Habashy KJ*, &lt;b&gt;Cewe P*&lt;/b&gt;, Atallah E, Singh A, Fletcher-Sandersjöö A, Bydon M, Fagerlund M, Jabbour P, Gerdhem P, Elmi-Terander A, Edström E. Neurosurgery. 2024 Sep 20. &lt;a href="https://doi.org/10.1227/neu.0000000000003173" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1227/neu.0000000000003173&lt;/a&gt;&lt;/p&gt;

The level of radiation awareness by surgeons and residents in spinal surgery does not match the ubiquity of fluoroscopy in operating rooms in the United States. The present method of monitoring radiation exposure may contribute to the current deficiency in radiation awareness. Current dosimeters involve a considerable lag from the time that the surgical team is exposed to radiation to the time that they are provided with that exposure data. The objective of the current study was to assess the feasibility of monitoring radiation exposure in operating room personnel during lateral transpsoas lumbar interbody fusion (LLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) procedures by using a wearable personal device with real-time feedback. Operating room staff participating in minimally invasive surgical procedures under a single surgeon during a 6-month period were prospectively enrolled in this study. All radiation dose exposures were recorded for each member of the surgical team (surgeon, assistant surgeon, scrub nurse, and circulating nurse) using a personal dosimeter (DoseAware). Radiation doses were recorded in microsieverts (μSv). Comparisons between groups were made using ANOVA with the Tukey post hoc test and Student t-test. Thirty-nine patients underwent interbody fusions: 25 underwent LLIF procedures (14 LLIF alone, 11 LLIF with percutaneous screw placement [PSP]) and 14 underwent MI-TLIF. For each operative scenario per spinal level, the surgeon experienced significantly higher (p < 0.035) average radiation exposure (LLIF: 167.9 μSv, LLIF+PSP: 424.2 μSv, MI-TLIF: 397.9 μSv) than other members of the team, followed by the assistant surgeon (LLIF: 149.7 μSv, LLIF+PSP: 242.3 μSv, MI-TLIF: 274.9 μSv). The scrub nurse (LLIF: 15.4 μSv, LLIF+PSP: 125.7 μSv, MI-TLIF: 183.0 μSv) and circulating nurse (LLIF: 1.2 μSv, LLIF+PSP: 9.2 μSv, MI-TLIF: 102.3 μSv) experienced significantly lower exposures. Radiation exposure was not correlated with the patient's body mass index (p ≥ 0.233); however, it was positively correlated with increasing patient age (p ≤ 0.004). Real-time monitoring of radiation exposure is currently feasible and shortens the time between exposure and the availability of information regarding that exposure. A shortened feedback loop that offers more reliable and immediate data would conceivably raise the level of concern for radiation exposure in spinal surgeries and could alter patterns of behavior, leading to decreased exposures. Further studies are ongoing to determine the effect of real-time dosimetry in spinal surgery.

Over the past 2 years, the COVID-19 pandemic has impacted the entire health-care profession, and spinal surgery had to adjust along with it. Although it may take years to truly assess the overall effect, early trends have clearly pointed toward a patient demand for telemedicine. Additionally, as COVID strained our hospitals and diverted critical resources away from elective surgical procedures, non-time-sensitive cases have been increasingly pushed out to outpatient surgical centers. Decreased inpatient elective surgical capability has also forced more patients to pursue extended nonoperative treatment modalities. Although it remains too early to determine the long-term impact of these shifts, we expect future studies to examine these issues extensively. This annual update on spine surgery includes an examination of peer-reviewed literature for all spinal conditions, in addition to abstracts presented at annual society meetings, over the past year. We chose these articles due to their potential to impact and advance our profession, with a preference toward the highest levels of evidence. Spondylotic Cervical Myelopathy Several interesting studies published recently added to our understanding of optimal surgical treatment for spondylotic cervical myelopathy. In the Cervical Spondylotic Myelopathy Surgical (CSM-S) randomized clinical trial, Ghogawala et al. compared the impact of anterior surgery with that of posterior surgery on patient outcomes1. In a select population in which clinical equipoise existed (exclusion of patients with kyphosis of >5°, ossification of the posterior longitudinal ligament, or segmental kyphotic deformity), 1-year and 2-year Short Form-36 (SF-36) Physical Component Summary (PCS) scores were not different between the 2 groups. The authors did identify a higher complication rate in the anterior surgery group, with dysphagia predominating. The major complication rates did not differ. Interestingly, in the nonrandomized analysis comparing laminoplasty, posterior cervical fusion, and anterior cervical fusion, the patients who underwent laminoplasty fared significantly better in physical function, complication rate, and resource utilization. Posterior cervical fusion is more commonly performed in the United States, and a recent study demonstrated that laminoplasty is likely underutilized despite growing evidence for improved performance metrics2. Current literature has mixed results with regard to determination of the optimal lower instrumented vertebra (LIV) in long posterior cervical fusions. In addressing the question of crossing the cervicothoracic junction, Truumees et al.3 evaluated patient-reported outcomes, radiographic outcomes, and revision rates in fusions stopping at C6/7 or T1/2 in a retrospective analysis of 264 patients with at least a 2-year follow-up. Patient-reported outcome measures improved equally in both groups. Radiographic outcomes were similar between groups, with both groups demonstrating similar improvement in cervical lordosis. The study did not detect a difference in revision rates, but was not powered to do so. Patients who underwent fusions into the thoracic spine did have more blood loss and longer operative time. Similarly, in a retrospective cohort study with a 4-year follow-up, Guppy et al. did not identify a difference in reoperation rates for adjacent segment disease4 or pseudarthrosis5 when cervical fusions were stopped at C7 or T1/T2. In the absence of extenuating factors, stopping at C7 may be a reasonable option given the lower morbidity and complication rate, although further work is needed in this area. Cervical Radiculopathy Numerous studies have been published comparing cervical disc arthroplasty with anterior cervical discectomy and fusion (ACDF). However, many of these studies may have been biased by industry sponsorship and a lack of blinded outcome assessment. The Norwegian Cervical Arthroplasty Trial (NORCAT) was designed as a blinded and randomized clinical trial of 136 patients comparing patient-reported outcomes after ACDF or cervical disc arthroplasty for single-level disease6. The patients and surgeons were blinded, with the treatment arm revealed to the surgeon only after neurologic decompression was completed. Both groups demonstrated a significant improvement in the Neck Disability Index (NDI) at 5 years, without a difference observed between groups. Secondary outcomes, including neck pain, arm pain, and adjacent segment disease, were not different between groups. The reoperation rate was not significantly different between groups, and nearly all reoperations were at the index level. Only 1 patient underwent reoperation for adjacent segment disease at 5 years. This study demonstrates that clinical outcomes are likely independent of implant choice; however, the effect on adjacent segment disease needs to be addressed with longer-term follow-up. The 10-year Investigational Device Exemption (IDE) trial data for the Bryan and Mobi-C cervical disc arthroplasty devices are now available. In a study comparing adverse events between the Bryan cervical disc arthroplasty and ACDF, Loidolt et al. demonstrated a similar rate of adverse events over a 10-year period7. The rate of revision surgery at the index level was not significantly different between the 2 groups. The rate of adjacent level surgery in the ACDF group trended higher (15.8% compared with 9.7%) but did not reach significance at 10 years. Additionally, the 10-year outcomes from the Mobi-C IDE trial were published8. This study was limited by lack of an ACDF control group and had an approximately 73% follow-up rate from the original cohort. At 10 years, the authors identified a rate of revision surgery of 5.1% at the index level and 4.3% at the adjacent level. No serious adverse events were reported between 7 and 10 years. One of the most common symptoms after anterior cervical surgery is dysphagia. In a meta-analysis of 7 randomized controlled trials, Garcia et al. evaluated the dysphagia rate after ACDF with prophylactic administration of local or intravenous corticosteroid9. The study provides moderate-quality evidence that the administration of corticosteroids reduces the dysphagia rate and severity after ACDF. A subgroup of studies on the pseudarthrosis rate did not identify a difference. No infections were reported in this meta-analysis. In a recent, well-designed, randomized, and double-blinded controlled trial, Kim et al.10 corroborated these results: after undergoing multilevel ACDF, patients received retropharyngeal corticosteroid or placebo. Dysphagia was assessed with validated outcomes. The corticosteroid group had significantly better scores at all time points up to 1 month. These results suggest that corticosteroid administration likely reduces dysphagia rates, although the effect on pseudarthrosis remains to be fully elucidated. Lumbar Disc Herniation and Lumbar Degenerative Conditions Lumbar disc herniation remains a common clinical problem11. Several recent studies have examined options for the management of lumbar disc herniation. In a randomized controlled trial, Wilby et al. compared microdiscectomy with transforaminal epidural corticosteroid injection in patients with persistent radicular pain for <1 year secondary to disc herniation12. The authors found that there were no significant differences in pain scores between the epidural injection group and the surgery group, although 18% of the injection group underwent a surgical procedure prior to the completion of the study. The authors also posited that a surgical procedure is less cost-effective than an epidural injection, although this work is ongoing. In a systematic review and meta-analysis, Wei et al. compared open microdiscectomy, microendoscopic discectomy, percutaneous endoscopic discectomy, tubular discectomy, and percutaneous discectomy13. The authors found no significant differences between most approaches, except that percutaneous endoscopic discectomy had the best safety and efficacy, although this review was limited by the heterogeneity of the included studies. Ran et al. compared computed tomography (CT)-navigated percutaneous endoscopic discectomy with open microdiscectomy in 68 patients and found that the percutaneous discectomy group reported less postoperative back pain and the percutaneous approach generated lower serum markers of muscle trauma14. In a systematic review and meta-analysis, Gadjradj et al. found that moderate-quality evidence supports percutaneous transforaminal endoscopic discectomy as an equivalent treatment to open microdiscectomy, but there is a paucity of high-quality evidence comparing the 2 approaches15. Additionally, the topic of annular repair or other implants to reduce reherniation rates has been reexamined in the last 2 years. In a systematic review, Rickers et al. found a trend toward improved outcomes with annular repair. In contradistinction to the prior study, the authors also found that percutaneous discectomy performed the worst of all current surgical approaches, although, overall, there were no significant differences between treatments16. Additionally, the risk of bias was high in 15 of the 32 included studies. The debate with regard to the optimal management protocol for lumbar degenerative spondylolisthesis has continued lately. Heemskerk et al.17 compared open transforaminal lumbar interbody fusion (TLIF) and minimally invasive surgery (MIS)-TLIF for patient-reported outcomes, and Droeghaag et al.18 compared open TLIF and MIS-TLIF for cost-effectiveness. Heemskerk et al. found that MIS-TLIF and open TLIF had equivalent outcomes at the 2-year follow-up; Droeghaag et al. found that MIS-TLIF is more cost-effective than open TLIF. These results suggest that MIS-TLIF may be an important tool in the long-term management of lumbar degenerative spondylolisthesis. However, in a meta-analysis of 7 studies, Zhang et al. found that oblique lateral interbody fusion with supplementary posterior fixation yielded better improvements in symptoms compared with MIS-TLIF and was associated with a shorter operative time19. Furthermore, the type of posterior fixation for lumbar fusion remains controversial. In a systematic review and meta-analysis, Chang et al. compared traditional pedicle screws with cortical-based trajectory screws for the treatment of lumbar degenerative spondylolisthesis in patients who underwent interbody fusion20. The authors found that cortical screws were associated with decreased operative time and less blood loss during the surgical procedure, but the overall fusion rates were similar at 1 year. Additionally, Zhu et al. performed a systematic review and meta-analysis comparing MIS-TLIF and endoscopic TLIF, which demonstrated the noninferiority of the endoscopic approach compared with traditional minimally invasive techniques21. The applications of navigation and robotics continue to rapidly expand in the field of spinal surgery. Fu et al.22 and Zhou et al.23 both performed meta-analyses comparing the freehand placement of pedicle screws with robotic-assisted placement. Both studies found significant improvements in pedicle screw accuracy, including reduced violation of the cephalad facet joint and intraoperative radiation dose, with robotic assistance, although revision rates for screw malpositioning were similar in the latter article. Klingler et al. performed a randomized trial of fluoroscopically assisted MIS-TLIF and navigated TLIF and found that the type of navigation used in the study did not significantly reduce radiation exposure to the surgeon, while simultaneously increasing radiation exposure to the patient24. Therefore, the role of navigation and robotics is still being developed. There has also been increasing interest in single-position prone lateral lumbar interbody fusion as an option for patients requiring surgical stabilization for spondylolisthesis. Walker et al. performed a retrospective review of 30 patients with spondylolisthesis undergoing either prone or lateral decubitus lateral interbody fusion with posterior instrumentation25. The authors found that the prone position yielded significantly improved segmental lordosis compared with the traditional position. Additionally, Guiroy et al. performed a systematic review comparing these approaches and found that single-position lateral decubitus trended toward shorter operative time and hospital stay, although only 4 studies were included26. Interestingly, in a separate systematic review and meta-analysis, Mills et al. examined lateral decubitus compared with the prone position without repositioning and found that the single-position lateral decubitus reduced operative time and radiation exposure compared with the prone position, and the improvement in segmental lordosis was higher in the prone group27. However, pedicle screws placed using the lateral decubitus position had a higher rate of complications. Perioperative Pain Management There has been increasing interest in the utilization of local or regional anesthesia for pain control in patients undergoing lumbar spinal surgery. Erector spinae plane blockade continues to gain traction in this regard. In randomized controlled trials, Jin et al.28 examined the efficacy of an erector spinae plane block in patients undergoing lumbar laminoplasty, and Zhu et al.29 and Goel et al.30 examined the efficacy of an erector spinae plane block in patients undergoing single-level lumbar fusion. The authors found that erector spinae plane blockade resulted in significantly reduced postoperative pain scores, reduced opioid consumption, and higher patient satisfaction, suggesting that erector spinae plane blockade should become more routinely utilized in the perioperative period. Liposomal bupivacaine injection is an additional multimodal pain management technique to reduce postoperative pain and opioid consumption. Nguyen et al. performed a systematic review of retrospective cohort studies and randomized controlled trials investigating this technique and found that lower-quality evidence supports its use and moderate-quality studies were equivocal31. The authors maintained that higher-quality studies are needed before the efficacy of this technique can be fully appreciated. Multimodal anesthesia and various enhanced recovery after surgery (ERAS) postoperative pain management protocols have been developed to expedite patient recovery and improve satisfaction after spinal surgery. Recently, there have been several high-quality studies adding to the data on this topic. Soffin et al. published a trial of 56 patients randomized to either the ERAS protocol after lumbar fusion or traditional postoperative pain management, finding decreased opioid consumption and improved patient-reported pain scores in the immediate postoperative period with the ERAS protocol32. However, significant clinical impact was not proven with the ERAS protocol, which was possibly related to the small sample size. In a randomized controlled trial, Kraiwattanapong et al. similarly evaluated multimodal drug infiltration in the postoperative wound bed, demonstrating that this technique reduced postoperative pain scores and opioid consumption33. Sharaf et al. performed a randomized controlled trial comparing postoperative physical therapy with and without neural mobilization in patients who underwent lumbar decompression for stenosis; the authors found that the addition of neural mobilization improved outcomes across all patient-reported outcome measures34. Lastly, Ma et al. performed a prospective randomized trial evaluating the utility of postoperative spinal orthoses after MIS-TLIF35. The authors found that the use of a postoperative orthosis had no significant effect on the Oswestry Disability Index (ODI) or visual analog scale pain score at 6 or 12 months after MIS-TLIF. Additionally, the orthosis had no effect on the fusion rate at the final follow-up. Adult Spinal Deformity Surgical decision-making for patients with adult spinal deformity is complex. In several recent studies, authors have examined the risk-and-benefit calculation that aids our surgical indications, patient optimization, and preoperative counseling. The Prospective Evaluation of Elderly Deformity Surgery (PEEDS)36 study illustrates the potential benefit of spinal deformity surgery: this prospective, multicontinental study evaluated disability (ODI) in patients ≥60 years of age who underwent spinal deformity surgery. The authors demonstrated that, after an initial recovery period, 70% of patients experienced at least 10% improvement from their baseline disability, which was sustained at 2 years. Meanwhile, approximately 25% of patients reported no change from baseline and approximately 5% of patients reported worsening of the disability. Importantly, although there was an overall significant improvement in disability, the mean ODI of 27% at 2 years was still worse than normative values, and was consistent with moderate disability. This article also stratified the shift in ODI based on preoperative ODI deciles, which is a useful counseling tool for shared decision-making. Similar findings were identified in the 5-year outcomes reported by the Scoli-RISK-1 Study Group37. This study was limited by a 5-year follow-up rate of 28%, but identified a significant improvement in patient-reported outcomes, with 62% of patients having a clinically meaningful improvement in the ODI score. Numerous studies have shown the complication profile of deformity surgery. The 5-year results from the Scoli-RISK-1 Study Group demonstrated worse lower-extremity motor scores in 9.3% of patients who were available for follow-up at 5 years38. This rate was improved from 14% at the time of hospital discharge and was unchanged from 2 years postoperatively. In a recent study, Lakomkin et al.39 helped to contextualize the surgical invasiveness of deformity surgery by comparing it with other major operations. Using a variation of the validated Postoperative Morbidity Survey score, the authors added length of hospital stay and operative time to develop the novel Surgical Invasiveness and Morbidity Score (SIMS). Using the National Surgical Quality Improvement Program (NSQIP) database and controlling for comorbidities, the authors compared SIMS across major surgical procedures. Adult spinal deformity surgery fared better than coronary artery bypass grafting, abdominal aortic aneurysm repair, and cystectomy, performed similarly to mitral valve replacement, and was, overall, worse than prostatectomy, total shoulder arthroplasty, and hip fracture fixation. This study provides an intuitive counseling tool for patients considering adult spinal deformity surgery. Several studies have shown the importance of patient frailty as a predictor of outcomes and complications. Passias et al.40 demonstrated that frailty was independent of chronological age in predicting positive outcomes in adult spinal deformity surgery. Patients ≥70 years of age who were not frail fared better than elderly patients who were frail or severely frail. Gum et al.41 demonstrated that the cost of quality-adjusted life-year (QALY) was impacted more by patient frailty than by surgical invasiveness. Frail and severely frail patients had significantly and incrementally higher costs per QALY than non-frail patients. Surgical invasiveness did not have a substantial impact on cost per QALY. The authors recommended focusing on patient optimization with respect to modifiable risk factors to improve cost optimization. These studies help to understand the risk and benefit of adult spinal deformity surgery and provide an increased awareness of patient factors that may impact outcomes. Nonoperative Treatments Spine surgery continues to evolve with the rest of the surgical profession, and, as many have proven, high-quality randomized controlled trials are difficult to perform with surgical procedures. In contrast, our interventional pain colleagues may be better positioned to conduct studies within this gold standard of evidence-based medicine. Their ability to do so, coupled with an increase in the nonoperative treatment environment, has created an exponential growth across the United States at a time when our patients were hesitant to seek hospital-based care. A thorough discussion of all available pain management procedures is beyond the scope of this update, but we believe that it is particularly important that all orthopaedic surgeons understand the basics behind these procedures and the early evidence to support their use. We do advise the reader that each of the studies in this section was industry-funded. The minimally invasive lumbar decompression (mild) procedure is approved by the U.S. Food and Drug Administration (FDA) for the treatment of neurogenic claudication and gained approval for reimbursement by the U.S. Centers for Medicare & Medicaid Services (CMS) in 2017. The procedure uses a small portal to remove part of the lamina and ligamentum flavum using radiographic assistance. Most recently, in 2021, Deer et al. published the 6-month results of a randomized controlled trial comparing the mild procedure with conventional medical management and found the mild procedure to have superior results, albeit in very early results42. Multiple interspinous devices are currently available on the market, and we have seen an increased use among our pain management colleagues. These devices have an established role in the management of neurogenic claudication, but their specific indications continue to evolve. Schenck et al. recently reported the results of their 5-year randomized controlled trial of interspinous devices compared with decompressive surgery and found similar results, but with a higher risk of reoperation within the first 2 years following use of interspinous devices43. Intraosseous basivertebral nerve ablation procedure was approved by the FDA in 2016 for the treatment of chronic low back pain in patients with disc degeneration and Modic end plate changes. This procedure has recently demonstrated positive results. Fischgrund et al. performed a double-blinded randomized trial, finding that the ablation of the basivertebral nerve yielded continued improvement in pain and function at a mean of 6.4 years postoperatively in this challenging patient population44. Telemedicine in Spine Surgery With the COVID-19 nearly the entire spine a in surgical procedures and an increase in The of and there has been exponential growth within the most of the literature on the and with articles evaluating the long-term outcomes of so. Several authors validated the performance of the with an on the neurologic Similar to the rest of the the spine to back with Over the past 2 years, we have different and expect to continued growth of this important advance forced by the Although this has been a of the it not the among colleagues in At the time of this all future society are currently to be at the Spine in in the Cervical Spine in in the in in the Lumbar Spine in in the Spine in and the of in in The of a of recently published studies related to the that received a higher of In addition to articles in this update, 6 other articles to spine surgery are to this review after the standard with a each article to help further in an evidence-based in this area. with or without fusion in degenerative lumbar spondylolisthesis. In a noninferiority study, et al. evaluated all patients with lumbar degenerative spondylolisthesis with a of who were randomized to either decompression or decompression and fusion. The of and evidence of a were not into their The outcome was an improvement of the ODI score by At 2 years, an equivalent of patients had a clinically important improvement of the ODI in the group and in the decompression and fusion at 2 years, reoperation rates trended higher in the group at than in the decompression and fusion group at but this difference was not This study was limited by the heterogeneity of the included as the and of degenerative spondylolisthesis were not included in the reoperation rates be useful in understanding the of decompression in the of degenerative spondylolisthesis. this study useful to the debate fusion for degenerative but of the of patients who benefit most from decompression and fusion compared with decompression Current of adjacent segment following lumbar fusion a systematic review and meta-analysis of recent Spine The risk of adjacent segment degeneration at adjacent levels to lumbar fusion remains a clinical surgery has been developed to this et al. performed a systematic review comparing these and the reported rate of adjacent segment The authors found no significant differences in adjacent segment disease or reoperation between groups, although the analysis demonstrated lower of adjacent segment degeneration in the The of included studies was there still is no on surgery decreased adjacent segment a systematic review and meta-analysis comparing Spine In a systematic review and meta-analysis, et al. compared stabilization with fixation for lumbar had improved length of stay, operative and blood loss but worse loss of deformity at final Patient-reported outcomes were not significantly different between groups. The literature remains on which surgical approach is of arthroplasty fusion for patients with cervical a randomized clinical et al. performed a randomized clinical trial comparing single-level ACDF with cervical disc Patients were blinded to and surgeons were blinded to treatment neurologic decompression was completed. The outcome was the and the secondary outcomes were arm and neck pain scores, of reoperation rate, and adjacent segment There were 136 patients with follow-up at 5 years. scores significantly improved in both groups, without a difference observed between groups. No differences were in reoperation rate or adjacent segment This study demonstrated that neck disability scores were not significantly different between groups within 5 years. for adjacent segment disease and reoperation longer-term follow-up. of to surgical after spine surgery: a systematic review and meta-analysis. Pain et al. performed a systematic review and meta-analysis of studies only 6 were randomized controlled and found that the addition of in the wound after spinal as as and a of the 2 yielded significant in surgical corroborated by this systematic review, reduce after spine surgery. in a systematic review and meta-analysis of randomized controlled Spine et al. performed a systematic review and meta-analysis of the available literature comparing the use of orthoses with no in the management of The authors found that, overall, there were no significant differences between the group orthoses and the group with no with regard to pain scores or radiographic and recommended that treatment of not These findings studies on the topic.

Lumbar interbody fusion procedures have seen a significant evolution over the years, with various approaches being developed to address spinal pathologies and instability, including posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF). LLIF, a pivotal technique in the field, initially emerged as extreme/direct lateral interbody fusion (XLIF/DLIF) before the development of oblique lumbar interbody fusion (OLIF). To ensure comprehensive circumferential stability, LLIF procedures are often combined with posterior stabilization (PS) using pedicle screws. However, achieving this required repositioning of the patient during the surgical procedure. The advent of single-position surgery (SPS) has revolutionized the procedure by eliminating the need for patient repositioning. With SPS, LLIF along with PS can be performed either in the lateral or prone position, resulting in significantly reduced operative time. Ongoing research endeavors are dedicated to further enhancing LLIF procedures making them even safer and easier. Notably, the integration of robotic technology into SPS has emerged as a game-changer, simplifying surgical processes and positioning itself as a vital asset for the future of spinal fusion surgery. This literature review aims to provide a succinct summary of the evolutionary trajectory of lumbar interbody fusion techniques, with a specific emphasis on its recent advancements.

Radiation exposure to patients and spine surgeons during spine surgery is expected. The risks of radiation exposure include thyroid cancer, cataracts, and lymphoma. Although imaging techniques facilitate less invasive approaches and improve intraoperative accuracy, they may increase radiation exposure. We performed a systematic review to determine whether (1) radiation exposure differs in open spine procedures compared with less invasive spine procedures; (2) radiation exposure differs in where the surgeon is positioned in relation to the C-arm; and (3) if radiation exposure differs using standard C-arm fluoroscopy or fluoroscopy with computer-assisted navigation. A PubMed search was performed from January 1980 to July 2013 for English language articles relating to radiation exposure in spine surgery. Twenty-two relevant articles met inclusion criteria. Level of evidence was assigned on clinical studies. Traditional study quality evaluation of nonclinical studies was not applicable. There are important risks of radiation exposure in spine surgery to both the surgeon and patient. There is increased radiation exposure in less invasive spine procedures, but the use of protective barriers decreases radiation exposure. Where the surgeon stands in relation to the image source is important. Increasing the distance between the location of the C-arm radiation source and the surgeon, and standing contralateral from the C-arm radiation source, decreases radiation exposure. The use of advanced imaging modalities such as CT or three-dimensional computer-assisted navigation can potentially decrease radiation exposure. There is increased radiation exposure during less invasive spine surgery, which affects the surgeon, patient, and operating room personnel. Being cognizant of radiation exposure risks, the spine surgeon can potentially minimize radiation risks by optimizing variables such as the use of barriers, knowledge of position, distance from the radiation source, and use of advanced image guidance navigation-assisted technology to minimize radiation exposure. Continued research is important to study the long-term risk of radiation exposure and its relationship to cancer, which remains a major concern and needs further study as the popularity of less invasive spine surgery increases.

A case report of robotic-guided prone transpsoas lumbar fusion in a patient with lumbar pseudarthrosis, adjacent segment disease, and degenerative scoliosis